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A- 02lt;.�RS'COMPENSATION DECLARATION CEA 818364C(2-80)- VPUCATION FOR (f'ERU�%U T•
r ,y a1L;'Mn that I have a certificate of consent to self
C5y all>insure, or a certificate of Workers'Compensation Insurance,or % GL f �� -' HEATING-VENT ILATING-AI R CONDITIONING
a certifit� copy thereof(Sec. 3800,Lab C.) \ I O —G LLJJ
Policy No/V C
Certified copy is hereby furnished l vI COUNTY OF LOS ANGELES BUILDING ARiD SAFETY
0 Certified copy is filed with the county building inspection r
Po rtment.. FOR APPLICANT TO FILL IN BUILDING —��
Date _ _ Applicant �.o �""� (PRINT OR TYPE ONLY) ADDRESS L/ J
CERTIFICATE OF EXEMPTION FROM WORKERS' NO. TYPE OF APPLIANCE OR EQUIPMENT FEE LOCALITY / �f7L�(�JTy��✓C'� '
COMPENSATION INSURANCE NEAREST i n �' ��/A
(This section .need not be completed if the work involved ABSORPTION UNIT, BTU CROSS ST. (3 �T a
by the permit is for one hundred dollars ($100) or less.) DISTRICT NO PRO.ESSED BY O
I certify that in the performance of the work for which this AIR HANDLING UNIT,CFM / ,
permit is issued,'.1 shall not employ any person in any manner , D �C t"� 0
so as to become subject to the Workers' Compensation Laws. BOILER, BTU
APPROVAL$ DATE INSPEC')RSSIGN ATUPE V
Date Applicant J_ COMPRESSOR BTU q"zO JDvo ROUGH ✓`; ' d
NOTICE TO APPLICANT: If, after making this Certificate of VENTILATION SYSTEM FINAL / -Z
Exemption; you should become subject to the Workers' _
Compensation provisions of the Labor Code, you must forth- EVAPORATIVE COOLER VALI ATION
with comply ,with such provisions or 'this permit shall be
deemed revoked. ;
- FURNACE FAUGRAVITY
' LICENSED CONTRACTORS DECLARATION FLOOR BTU
I hereby affirm that I am licensed under provisions-of Chapter HEATER SUSPENDED UNIT
9 (commencing with Section 7000) of Division 3 of the Busi- WALL
ness and Professions,Code, and my license is in full force'aind
effect '! `�Z
License NumberC_7L_(7/�`/—'n"b Lia Class"
Contractor_l�1!L Date 'F
11
'I am exempt from the licensing requirements as I am a ;�._d{r 21'50
licensed architect or a registered professional engineer Plan check fee 25% of above. � �t���
acting in my professional capacity (Section 7051, -Bus-
iness and Professions Code). PERMIT ISSUING FEE $ 20 5
Lic.or Reg.No. Date. TOTAL FEE
Ti G
0� i t r-A
�a=t <.
HOME OWNER-BUILDER DECLARATION PLAN CHECK APPLICANT i
I hereby affirm ,that I am exempt from- the Contractor's NAME
License Law for the following reason (Section 7031 5, Busi- 9
ness and I�rofessions Code). -ADDRESS -r,, sf 1
I, as owner of the property, will do the work and the
structure is not intended or-offered for 'sale (Section CITY �/! /�/�����j TEL NO('/C/ ,Qa 602 ..69
7044, Business and Professions Code) —� Q 8 L 0-
OWNER-
OI,as owner of the'property, am exclusively contracting- _•1 7 `�/�
with licensed contractors to construct - .the project MAIL ,
(Section 7044, Business and Professions Code). - ADDRESS
CITY i
CONSTRUCTION LENDING.AGENCYTEL.NO
_ / D///�� /)(Jf 0
I hereby affirm that there is a construction lending agency /r3`( ���t� C� -
for the performance of the work for which this permit is CONTRACTO —/_ L
issued(Sec 3097,Civ.C).
Lender's Name ADDRESS /9 (_/ f, -4 [ -
Lender's Address ' e-V
CITY / TEL NO
I certify that I have read this application and state that the STATE
above information is correct. I agree to comply with all County LICENSE NO. Z�- CLASSLIC II
ordinances and State laws regulating Heating',Ventilating and
Air Conditioning, and he authorize representatives of this SEE REVERSE FOR EXPLANATORY LANGUAGE,
County to enter upon the above-mentioned property,for
- °1Sp P poses.
Signa/re of Perm tee�! Datv 14,